Fillable Nightclub Package Supplemental (Access E&S Insurance Services)

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Nightclub Package Supplemental (Access E&S Insurance Services)

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The Nightclub Package Supplemental (Access E&S Insurance Services) form is 6 pages long and contains:

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  • 26 check-boxes
  • 191 other fields

Country of origin: US
File type: PDF

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Access E&S Insurance Services, Inc.
www.access-es.com
RBTAPP 10/2012 Page 2 of 6
Are you located near a college campus? Yes No
Type of area? Industrial/Commercial Residential Rural Other
Does the applicant provide any catering services? Yes No
Total Annual Receipts:
Current Year 1
st
Prior Year 2
nd
Prior Year
Food $ _______________ $ _______________ $ _______________
Alcohol $ _______________ $ _______________ $ _______________
Cover Charges $ _______________ $ _______________ $ _______________
Delivery Service $ _______________ $ _______________ $ _______________
Other $ _______________ $ _______________ $ _______________
Property and Premise Safety Information Yes No
1. Do you have a building maintenance program?
2. Is the building sprinklered?
3. Are all exits properly marked and lighted?
4. Is a secondary means of egress (exits) provided for each floor having public access?
5. Does the applicant have and practice an evacuation plan?
5. Are there any auxiliary electrical supply systems?
6. Are all smoke detectors properly maintained?
7. Is there a fire extinguishing system in the kitchen?
8. Are there any apartments or other type of occupancies in the building?
9. Does the kitchen have a deep fat fryer? If so, is it protected by an automatic fire
extinguishing system?
10. Is the fire automatic extinguishing system wet system?
11. Does applicant have a contract in place for hood & duct cleaning?
12. Does the applicant have any pyrotechnics exposure?
13. Does the applicant have any mechanical rides, climbing walls, foam machines or
inflatables?
14. Does the applicant conduct any physical contests or events inside or outside the facility?
If yes, describe
15. Is the risk located on a beach, vessel, dock or pier?
16. Has the applicant ever been cited for building code, health or liquor violations? If yes,
describe citation:
RBTAPP 10/2012 Page 3 of 6
Entertainment Information (If applicant has more than 1 location, specify location number applicable to
each form of entertainment)
1. Is there any type of entertainment listed below:
DJ Frequency Location
Stage/Floor Show Frequency Location
Live Band Frequency Location
Comedy Acts Frequency Location
Karaoke Frequency Location
Piano/Guitar Player Frequency Location
Solo Vocalist Frequency Location
Billiards Location
Adult/Exotic Dancing Location
Slot/video poker machine Location
2. Does the applicant have a dance floor? Yes No
If yes, what is the size of the dance floor?
How often is the floor inspected for slip and fall hazards?
Is the floor raised? Yes No
If so, does it have a railing around the entire floor?
3. What type of music is the predominant music played?
Classic Rock Rap/Hip Hop Country Pop
Liquor Liability Information
1. Name of Liquor License Holder & License Number:
2. Does the applicant ever sell or serve alcohol away from the premises?
3. Are all alcohol servers certified in a Formal Alcohol Training Course?
Advise name of course (SERVSAFE, TIPS, CARE, etc):
4. What time does the sale or service of alcohol cease?
5. Does the club use measuring or pouring devices for drinks?
6. Are employees allowed to consume alcohol during their hours of employment or service?
7. Does the applicant have knowledge of any fines or citations for violation of law or ordinance related to illegal
activities or the sale of alcohol at this location within the past five years? If yes, describe:
RBTAPP 10/2012 Page 4 of 6
8. Has the applicant had any reported liquor liability and/or assault and battery claims or notification of
potential liquor liability and/or assault and battery claims within the past five years? If yes, describe:
9. Does or will the applicant ever offer:
a. Any drink specials/happy hours? Yes No
b. Drink specials/happy hours lasting longer than 3 hours? Yes No
c. Drink specials/happy hours after 9:00pm? Yes No
d. Single drink servings larger than 24 ounces? Yes No
e. Complimentary drinks? Yes No
f. "All you can drink" specials? Yes No
g. "BYOB" bottle service or set-ups? Yes No
h. “Flaming shots” Yes No
10. Are IDs checked at the door or at the time of service?
Are electronic devices used to verify integrity of ID presented? Yes No
11. What is the lowest price of beer offered?
12. What is the lowest price of wine or liquor offered?
13. Does the applicant offer a ride service to intoxicated persons? Yes No
14. Does the applicant have a policy of not selling alcohol to intoxicated persons? Yes No
Security Information
1. Are security personnel: Employees Contracted Both
a. If applicant uses employees:
Are background checks completed on all security employees? Yes No
Do all security bouncers sign waivers? Yes No
Does the applicant train all security employees on proper security
and removal of patrons? Yes No
b. If applicant uses contractors:
Does the applicant have a written agreement with the contractors? Yes No
2. Does the applicant engage police officers for work in or about the premises? Yes No
If yes, how are they engaged and invoiced?
With Municipality Secondary Employment Company Individually
3. Are firearms permitted or kept on premises? Yes No
RBTAPP 10/2012 Page 5 of 6
4. Are security personnel responsible for ID checks? Yes No
5. Are incident logs documenting when a person was refused service or other
alcohol related events maintained? Yes No
6. Do you have video surveillance? Yes No
Describe
7. How many days do you keep the video tapes___________________
8. What procedures are in place for entry control (capacity limits)?
9. Do you have a Standard Operating Procedure for selecting your
security personnel? If so, please attach a copy. Yes No
Automobile Information
1. Do employees ever use their own autos for work? Yes No
2. What limit of liability is required for employees using their auto’s for work? ________________
3. Are there standards for employees using owned /non owned autos (age, MVR)? Yes No
List _______________________________________________________________________________
4. Does the applicant provide group transportation or livery service? Yes No
5. Does applicant provide delivery service? Yes No
6. Does the applicant offer valet parking? Yes No
If yes, are valet’s Employees? Contracted?
Employee/Hiring Information
1. Do hiring procedures include background checks, job history and references? Yes No
2. Can cashiers tamper with customer's checks or register receipts? Yes No
3. Does the applicant have a written Sexual Harassment Policy? Yes No
4. What controls/procedures are in place to limit/control employee theft?
RBTAPP 10/2012 Page 6 of 6
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Nightclub Package Supplemental (Access E&S Insurance Services)

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Completed 8 January 2021

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